Provider Demographics
NPI:1922036086
Name:FULLEM, BRIAN WILLIAM (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:WILLIAM
Last Name:FULLEM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 N MCMULLEN BOOTH RD
Mailing Address - Street 2:#C-2
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-2130
Mailing Address - Country:US
Mailing Address - Phone:727-330-7646
Mailing Address - Fax:727-330-7645
Practice Address - Street 1:1700 N MCMULLEN BOOTH RD
Practice Address - Street 2:#C-2
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-2130
Practice Address - Country:US
Practice Address - Phone:727-330-7646
Practice Address - Fax:727-330-7645
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT556213ES0103X
FLPO3445213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U19859Medicare UPIN